Acute Cervical Injuries In Football Mark A. Giovanini MD NeuroMicroSpine Specialist Neurospine Institute Gulf Breeze Florida Sandestin Executive Health and Wellness Center Orlando Florida Park City Utah www.neuromicrospine.com www.neurospineinstitute.org

Kevin Everett Spinal Cord Injury

Scope of Cervical Injuries 50% of Sport Injuries are to the C-spine Football and Rugby have highest frequency 10-15% of football injuries are cervical spine injuries Most are self limited and do not have permanent neurologic injury. Scope of Cervical Injuries

Types of Neck Injuries Nerve root or brachial plexus injuries Acute cervical sprains/strains Intervertebral disk injuries Cervical fractures Cervical stenosis and transient spinal cord injury Types of Neck Injuries

Cervical Anatomy

Mechanism of Injury Hyper-flexion and Axial loading Fractures, Herniated Discs and Ligamentous Cervical Root Injury, Spinal Cord Injury Hyper-extension Injuries Ligamentous, Posterior column Fractures Spinal Cord Injury, Contusions, Central Cord Syndrome Mechanism of Injury

Nerve root/brachial plexus injury Cervical Root Stinger Brachial Plexus Stinger Nerve root/brachial plexus injury

Cervical Root Injury Lateral Compression

Cervical Root vs. Plexus Pain, paresthesia, weakness or numbness in arm Lateral compression towards arm Painful ROM of neck Work up of neck to RO instability RTP after eval and sx resolve Pain, paresthesia, weakness or numbness in arm Distraction away from arm Painless ROM of neck Return to play when sx resolve Cervical Root vs. Plexus

Cervical sprain Most common injury to spine Axial compression to spine Pain in paraspinal region in neck No arm symptoms or neurologic symptoms Cspine xray with flexion/extension RTP when symptoms resolve Cervical sprain

Acute onset of neurologic deficits or pain down one or more extremities. Ruptured disc with root or cord compression Root involves one extremity Cord involves more than one extremity Persistant symptoms radiographs normal MRI evaluation for persistant neurologic symptoms Cervical Disc Injury

Cervical Disc Herniation Football Injury 2 1 y / o m i d d l e L B C o l l e g i a t e l e v e l T r a n s i e n t C C N 1 5 m i n . a l l e x t . R e s i d u a l R C 7 r a d i c u l o p a t h y P T , P a i n a n a g e m e n t S u r g e r y D e s i r e s r e t u r n t o f o o t b a l l Cervical Disc Herniation Football Injury

Cervical disc herniation post operative Return to play in 8 to 12 weeks Outpatient operation Symptoms resolved with normal neurologic exam No restrictions Risk of adjacent level trauma unknown Cervical disc herniation post operative

Cervical disc herniation anterior cervical discectomy and fusion Risk of adjacent level deterioration is 100% Risk of subsequent clinical injury unknown Player assumes risk of subsequent injury. Cervical disc herniation anterior cervical discectomy and fusion

Cervical Fracture Rare Hyper-flexion/Axial Loading Neck Pain Palpable tenderness May or may not have SCI Highly unstable Needs Immobilization and Transport to tertiary care center Surgery necessary RTP is never possible Cervical Fracture

Syndromes of Spinal Cord Injury Clinical Syndromes Clinical effects Central Cord Syndrome Brown-Sequard Syndrome Transient Quadriplegia Permanent Quadriplegia Cervical Radiculopathy Both hands>arms>legs Unilateral arm/leg Transient motor/sensory loss all 4 extremities Permanent loss all 4 ext. Unilateral arm motor/sensory/pain Syndromes of Spinal Cord Injury

Central Cord Injury

Central Cord Neuropraxia CCN Transient post-traumatic paralysis of the motor and sensory tracts of the spinal cord Transient Spinal Cord Injury TSCI Annual Incidence 17/100,000 High School Football 2.05/100,000 Collegiate Football Boden, B.P. 2006 Am J Sports Med Described by Torg in 1986 Mechanism is hyperextension or flexion injury May be associated with Abnormal Pathology Cervical Stenosis Cervical Spondylosis, Disc Herniation May be associated with Normal Anatomy Central Cord Neuropraxia CCN

Cervical Stenosis Congenital Acquired Pavlov Ratio < .8 Prevalence 8-29/100 football players MRI-Functional reserve Acquired Developmental Compressive Cervical spondylosis Cervical Disc Herniation Cervical Stenosis

Cervical Stenosis CCN/TSCI Football player who experienced a TSCI Complete resolution of symptoms within 24 hrs. Allowed to return to play after complete resolution of symptoms Cervical Stenosis CCN/TSCI

TSCI Normal Anatomy Remove from contest Evaluate Return to Play Abnormal Anatomy Remove from play Evaluate Same Treatment Disc herniation Neurologic  Sx Non-Neuro ?? Spinal Stenosis Neuro Sx Non-Neuro?? Return to Play ??????????? Normal Anatomy Remove from contest Evaluate Xray/Dynamic Xray MRI Dynamic MRI Return to Play Symptoms resolve Single episode Imaging normal Adequate Functional Reserve TSCI

Return to Play Guidelines Recognize Injury Neurologic/Non-Neuro Symptoms/signs resolved Anatomy Resolve pathology Stability of Cervical Spine Adjacent Levels Athletes future in particular sport Multiple opinions Return to Play Guidelines

Cervical Disc Replacement Lower incidence of adjacent level disease Made for athletes Return to play faster Cervical Disc Replacement

Minor Cervical injuries are common and usually self limited. Major Cervical Injuries are rare but can be catastrophic Recognition of Peripheral vs. Central injury is critical. Return to play Conclusions